Basic Information
| Provider Information | |||||||||
| NPI: | 1700070596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CO BOCO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DRIVE | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 N LINDSAY STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022250 | ||||||||
| FaxNumber: | 3368022251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 03/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Z00000X | 065257 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist | 222Z00000X | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist |
ID Information
| ID | Type | State | Issuer | Description | 7795044 | 05 | NC | MEDICAID |